Clinical relevance of the proposed sexual addiction diagnostic criteria: relation to the Sexual Addiction Screening Test-Revised.

ORIGINAL RESEARCH

Clinical Relevance of the Proposed Sexual Addiction Diagnostic Criteria: Relation to the Sexual Addiction Screening Test-Revised Patrick J. Carnes, PhD, Tiffany A. Hopkins, MA, and Bradley A. Green, PhD

The present article examines and compares the various diagnostic rubrics proposed to codify symptoms of sexual addiction, and then briefly summarizes the ongoing controversy on whether sexual addiction is a valid construct. Using the diagnostic criteria proposed by Carnes (2005), the prevalence rate of each criterion is examined in terms of scores on the Sexual Addiction Screening Test-Revised scales (Carnes et al., 2010). Differences in diagnostic criteria endorsement associated with sex, sexual orientation, and setting were also explored. Results from a clinical sample of men and women seeking treatment for sexual addiction demonstrated clinical relevance of the criteria, in that all but 3 criteria are endorsed at more than 50% of participants screening positive for sexual addiction on the Sexual Addiction Screening Test-Revised. Sex differences were also noted for endorsement rates of several of the criteria. Finally, several proposed criteria may pose a higher clinical threshold and thus be utilized by clinicians to identify patients with increased pathology. Results are discussed in the context of existing diagnostic frameworks across etiological perspectives. Key Words: comorbid disorders, cyber sex, sex addiction, Sexual Addiction Screening Test-Revised, sexual dependency inventory (J Addict Med 2014;8: 450–461)

S

exual addiction is a proposed model for understanding problematic hypersexual behavior characterized by sexual compulsivity, obsession, persistence, engaging in sexual behaviors despite negative consequences, and symptoms of withdrawal and tolerance related to sexual activity (Carnes, 2005; Garcia & Thibaut, 2010). Shaffer et al. (2004) proposes an addiction syndrome model, wherein substance-based and process addictions (eg, gambling, compulsive eating, and sexual addiction) evince a myriad of similarities in expression From the American Foundation for Addiction Research (PJC), Carefree, AZ; University of Southern Mississippi (TAH), Hattiesburg, MS; and Pine Grove Behavioral Health and Addiction Services (BAG), Hattiesburg, MS. Received for publication March 13, 2014; accepted August 2, 2014. The authors declare no conflicts of interest. Send correspondence and reprint requests to Patrick J. Carnes, PhD, International Institute for Trauma and Addiction Professionals, Carefree, AZ 85377. E-mail: [email protected]. C 2014 American Society of Addiction Medicine Copyright ISSN: 1932-0620/14/0806-0450 DOI: 10.1097/ADM.0000000000000080

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and biopsychosocial precursors and consequents, providing evidence for a possible shared etiology. Examples of such similarities include, but are not limited to, co-occurring disorders and addictions (Carnes, 1991; Ragan & Martin, 2000; Schneider et al., 2005), personality characteristics (MacKillop et al., 2011), neurological vulnerabilities (Ragan & Martin, 2000; Schmitz, 2005; Frascella et al., 2010; Olsen, 2011), and genetic (Ragan & Martin, 2000) and biological (Westreich, 2009) vulnerabilities. As a researchable phenomenon, sex addiction has been affected by emerging and growing concepts of addiction from a neurobiological point of view. David Redish and his colleagues (2008) used sex addiction in their extensive metareview of addiction affecting brain decision making. Redish pointed out that much controversy in addiction medicine was classically “having different parts of an elephant.” Nestler argued in his 2005 Royal Academy lecture for the importance of now understanding the “natural addictions” (Nestler, 2005). The American Society of Addiction Medicine formulated a position of addiction as a brain disease in which sex addiction was one of the ways it manifests. Recent research has explored parallels of sex addiction with other addictions using various neuroimaging strategies (Kuhn & Gallinat, 2014). A variety of books speak to the multiple addiction concepts and parallels. Most recently that genre includes Rosenberg and Feder (2014) but also Coombs (2004) and Freimuth (2009). Given the similarities of biological influences and symptom patterns, it follows that addictive disorders may share similar diagnostic criteria, and indeed, many current addictive disorders have a common nosological history. Addiction-related diagnostic criteria were first outlined for substance dependence (Rounsaville et al., 1986) and introduced in the Diagnostic and Statistical Manual, Third Edition, Revised (DSM-III-R; APA, 1987). These criteria were derived from the alcohol dependence syndrome delineated by Edwards and Gross (1976). Recent versions of the DSM (APA, 1994, 2000, 2013) continued this tradition and expanded the criteria to encompass 11 classes of substances. Pathological gambling shared 5 of the 7 dependence criteria with substance dependence in the DSMIV-TR (APA, 2000; Petry, 2002), illustrating the commonalities between behavioral and substance addictions. This idea was further reinforced by proposed revisions in the DSM-V, in which substance use disorders and gambling disorders are subsumed under the heading of Addiction and Related Disorders (O’Brien, 2011), with increased overlap in criteria. J Addict Med r Volume 8, Number 6, November/December 2014

Copyright © 2014 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.

J Addict Med r Volume 8, Number 6, November/December 2014

For more than 4 decades, various researchers of problematic sexual behavior have proposed potential diagnostic criteria (Table 1). When the literature is distilled from an atheoretical perspective, a number of consistencies emerge despite controversy in proposed etiology. For example, there is universal agreement for a criterion measuring the continuation of a sexual behavior despite problems or adverse consequences (eg, physical, financial, psychological, and social) and/or distress caused or worsened by the sexual behavior (Orford, 1978; Carnes, 1983, 1991, 2005; Goodman, 1998a, 1998b; Stein et al., 2001; Coleman et al., 2003; Kafka, 2010). Almost all authors advocate for inclusion of a criterion assessing a recurrent pattern of preoccupation or engagement in sexual urges, impulses, or behaviors (Orford, 1978; Carnes, 1983, 1991, 2005; Goodman, 1998a, 1998b; Kafka, 2010). In addition, multiple authors propose that individuals must frequently engage in sexual behaviors during time allotted for major role obligations (Orford, 1978; Goodman, 1998a, 1998b; Stein et al., 2001; Coleman et al., 2003; Carnes, 2005; Kafka,

Diagnostic Criteria & SAST-R

2010). Similarly, almost all authors propose that an individual must display an enduring desire or ineffective attempts to stop, reduce, or control their sexual behaviors (Orford, 1978; Carnes, 1983, 1990, 2005; Goodman, 1998a, 1998b; Stein et al., 2001), as well as preoccupation with the sexual behavior or associated preparatory activities (Orford, 1978; Stein et al., 2001; Coleman et al., 2003; Carnes, 2005; Kafka, 2010). In addition, several authors recommend a criterion requiring that an individual engage in sexual behaviors to a greater extent, or over a longer time, than planned (Carnes, 1983, 1991, 2005; Goodman, 1998a, 1998b; Kafka, 2010). Several authors also advocate for a criterion addressing the exorbitant amount of time spent planning for, participating in, or recuperating from a sexual behavior (Orford, 1978; Goodman, 1998a, 1998b; Carnes, 2005; Kafka, 2010). Finally, multiple authors recommend the inclusion of a criterion assessing the restriction or cessation of social, occupational, or recreational activities because of the sexual behavior (Carnes, 1983, 1991, 2005; Goodman, 1998a, 1998b; Kafka, 2010).

TABLE 1. Proposed Criteria for Sexual Addiction

Hypersexuality: Theory of Dependence Sex Addiction (Orford, 1978, (Carnes, p. 308) 1983, 1991)

Criteria 1. Recurrent failure (pattern) to resist sexual impulses to engage in specific sexual behavior 2. Frequent engaging in those behaviors to a greater extent 3. Persistent desire or unsuccessful efforts to stop, to reduce, or to control behaviors 4. Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experiences 5. Preoccupation with the behavior or preparatory activities 6. Frequent engaging in the behavior when expected to fulfill occupational, domestic, or social obligations 7. Continuation of behavior despite knowledge of having persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior 8. Need to increase the intensity, frequency, number, or risk of behaviors to achieve the desired effect or diminished effect with continued behaviors at the same level of intensity 9. Giving up or limiting social, occupational, or recreational activities because of their behavior 10. Distress, anxiety, restlessness, or irritability if unable to engage in the behavior C

X

X

Sexual Addiction (Goodman, 1998a, pp. 233-234) X

X

X

X

X

X

X

X

X

X

X

X

X

X

Nonparaphilic Compulsive Sexual Disorder Sex Addiction Hypersexual (Coleman (Carnes, Disorder et al., 2003) 2005) (Kafka, 2010)

X

X

X

Hypersexual Disorder (Stein et al., 2001, pp. 1592-1593)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

2014 American Society of Addiction Medicine


X

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Carnes et al.

A few authors delineate criteria related to tolerance and withdrawal. With regard to withdrawal, Carnes (2005) proposes that an individual experiences “distress, anxiety, irritability, or restlessness if unable to engage in the behavior” (pp. 1997). Goodman (1998a, 1998b) defines withdrawal characteristics more broadly as “physiologically . . . or psychologically described changes upon discontinuation of the sexual behavior” and that “the same (or closely related) sexual behavior is engaged in to relieve or avoid withdrawal symptoms” (pp. 233-234). In addition, tolerance is addressed by requiring that an individual experience either a decreased response to the same sexual behavior, or need an increased amount or intensification of sexual behavior to obtain the same effect (Carnes, 1990, 2005; Goodman, 1998a, 1998b). Several authors also propose exclusionary criteria, as currently seen in the DSM-V (APA, 2013) for substancerelated disorders. Proposed exclusions include symptoms because of the effects of a substance, such as a medication or drug of abuse (Stein et al., 2001; Coleman et al., 2003; Kafka, 2010); symptoms because of other disorders, such as a manic episode or an erotomanic delusional disorder (Stein et al., 2001); symptoms caused by a general medical condition (Stein et al., 2001; Coleman et al., 2003); and symptoms related to a developmental disorder (Coleman et al., 2003). Conversely, there is consistent disagreement regarding duration of symptoms necessary for diagnosis, with authors ranging from no duration (Orford, 1978; Coleman et al., 2003; Carnes, 2005), to 6 months (Kafka, 2010), 1 year (Goodman, 1998a, 1998b), 2 years (Carnes, 1990), and so forth. Controversy regarding the duration criterion likely stems from a lack of empirical support indicating a particular threshold of time needed for diagnosis. Disagreement is also prevalent when authors incorporate etiological issues into their observation of phenomena related to problematic sexual behavior. For example, the preliminary diagnostic framework proposed by Carnes (1990) required the presence of a hierarchy of problematic sexual behaviors. Similarly, Kafka (2010) requires problematic sexual behavior to occur in the context of dysphoric mood or stressful life circumstances. Although a full discussion of the etiological differences among proposed diagnostic frameworks is beyond the scope of this article, consistent agreement regarding shared phenomena of problematic sexual behavior indicates that this argument may not be necessary for the formulation of diagnostic criteria. The diagnosis and treatment using the sexual addiction model remains impaired without clearly defined and agreedupon diagnostic criteria. As described above, many authors have detailed atheoretical criteria, which closely resemble the DSM’s criteria for substance abuse or dependence; in fact, several authors have argued for direct substitution of sexual addiction terminology into these criteria (Carnes, 1983; Goodman, 1992; Irons & Schneider, 1999; Schneider & Irons, 1996). The paucity in the literature regarding the prevalence and applicability of specific diagnostic criteria within the sexual addiction population remains the largest obstacle in defining sexual addiction. The present study utilizes Carnes’ (2005) diagnostic criteria, delineated in the Comprehensive Textbook of Psychiatry, which are based on the diagnostic criteria of substance abuse

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and dependence. The development of these criteria was spurred on by inclusion in the DSM-III-R of criteria for sex addiction (302.87). Also, the controversies that then existed had more to do with compulsion versus addiction models. Carnes initiated a longitudinal study of 952 sex addicts and used a revised model of the criteria (2001), which in turn was published in 2 studies (2000 and 2012). These criteria have significant overlap with a number of diagnostic frameworks, while removing possible points of contention based in etiology and arbitrary decision making. The criteria closely resemble the 7 criteria described by the DSM-IV-TR (APA, 2000) for substance dependence, along with 3 additional criteria. One such criterion, dealing with obsession, is related to the “craving” criteria proposed for the current DSM-V (Ling, 2011). Leedes (2001) described obsession as one of the hallmarks of sexual addiction, interpreting obsession as a craving for connection and sexual activity. Another criterion matches more closely with that of DSM-IV-TR substance abuse, relating to the neglect of major role obligations because of sexual behaviors. Table 2 presents Carnes’ criteria for sexual addiction alongside the DSM-IV criteria for substance abuse and dependence, and DSM-V criteria for substance-related disorders. Although these criteria are utilized in sexual addiction treatment settings, they have only been minimally examined for their relevance to this population (Carnes, 2005). The agreement between authors as to these criteria, the homogeneity of criteria between this and other forms of addiction, and the clinical utility described by current practitioners (Carnes, 1991) suggest that these criteria should be applicable to sexual addiction. It should be noted that, in contrast to addiction models, researchers have proposed alternative models to explain hypersexual behavior (Steele et al., 2013; Ley et al., 2014). Even those from an addiction perspective saw value in hypersexuality as an overarching concept. There are problematic sexual behaviors, which are not consistent with either compulsivity or addiction perspectives (Finlayson et al., 2001). Some features of Parkinson’s serve as an example. From the beginning, the most vehement critics came from the standpoint that there was no problem. The concern was that normal sexual behavior would be pathologized on the basis of popular prejudice. “The Myth of Sexual Compulsivity” was scathing in its indictment of sex addiction as having the potential of pathologizing sexual minorities (Levine & Troiden, 1988). To this day, this position is taken that sex addiction is a myth. Ley et al. (2014) see the problems in the public’s reaction to the concept of sex addiction, further stereotyping that which is normal. Steel et al. (2013) describe sex addiction as a misperception of sexual desire and reject hypersexuality as a viable concept for the same reasons. Grubbs et al. (2014) see sex addiction as an extension of religiosity’s moral disapproval. Reid criticizes the science of the field on a number of levels (Kor et al., 2013). The common thread among all of the critics is that there is no science in the literature to document such a problem. The reader will note in this article that actually a great deal of thought and effort by many researchers went into thinking about viable criteria that would be independent of politics, subgroups, and the stereotyping of anyone. The purpose of this study was to help bring C





TABLE 2. Comparison of Sexual Addiction and Substance Use, Abuse, and Dependence Criteria in the DSM-IV and DSM-V Sexual Addiction Proposed Criteria 1. Repeatedly failed to resist impulses to engage in a specific sexual behavior 2. Engaged in sexual behaviors to a greater extent or over a longer period than intended 3. Long-standing desire, or a history of unsuccessful efforts to stop, reduce, or control sexual behaviors 4. Spent excessive time obtaining sex, being sexual, or recovering from sexual experiences

DSM-IV-TR Substance Abuse (A) and Dependence (D) Criteria

The substance use often taken in larger amounts or over a longer period than was intended (D) There is a persistent desire or unsuccessful efforts to cut down or control substance use (D) A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects (D)

5. Obsessed with preparing for sexual activities 6. Frequently engaged in sexual behavior when expected to be fulfilling occupational, academic, domestic, or social obligations 7. Continued sexual behavior despite knowing it has caused or exacerbated social, financial, psychological, or physical problems

8. Increased the intensity, frequency, number, or risk of sexual behaviors to achieve the desired effect, or experience diminished effect when continuing behaviors at the same level of intensity, frequency, number, or risk 9. Given up or limited social, occupational, or recreational activities because of sexual behavior 10. Become upset, anxious, restless, or irritable if unable to engage in sexual behavior

Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (A) Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (D) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (A) Tolerance, as defined by a need for markedly increased amounts of the substance to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount of the substance (D) Important social, occupational, or recreational activities are given up or reduced because of substance use (D) Withdrawal, as manifested by the characteristic withdrawal syndrome for the substance or when the substance is taken to relieve or avoid withdrawal symptoms (D) Recurrent substance use in situations in which it is physically hazardous (A) Recurrent substance-related legal problems (A)

DSM-V Substance Use Disorder Criteria

Substance is often taken in larger amounts or over a longer period than was intended There is a persistent desire or unsuccessful efforts to cut down or control substance use A great deal of time is spent in activities necessary to obtain substance, use the substance, or recover from its effects Craving, or a strong desire or urge to use the substance Important social, occupational, or recreational activities are given up or reduced because of substance use Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance Tolerance, as defined by either of the following: • A need for markedly increased amounts of substance to achieve intoxication or desired effect • A markedly diminished effect with continued use of the same amount of substance Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home Withdrawal, as manifested by the characteristic withdrawal syndrome for the substance or when the substance (or closely related substance) is taken to relieve or avoid withdrawal symptoms Recurrent substance use in situations in which it is physically hazardous

DSM, Diagnostic and Statistical Manual.

clarity and specificity to the problem. Moreover, we used data from the one group that had a unique perspective on it—the patients themselves. The authors do not propose that a sexual addiction model need be the only viable model for explaining problematic hypersexual behavior. Rather, we propose that an addiction model may be particularly valid and useful when applied to treatment seekers in clinical settings, and should be considered in the course of case formulation. We propose that diagnostic criteria for sexual addiction, constructed to parallel DSM criteria for substance-related disorders, should be valid indicators of hypersexual behavior of an addictive nature. We propose that the degree to which people seeking treatment for sexual addiction endorse those criteria has relevance to the validity and utility of an addictive model for hypersexual behavior. Furthermore, to the degree that an addiction model of hypersexual behavior proves to be valid, and congruent with other addiction and related syndromes, there should be considerable benefit de C

rived from transferring relevant risk factor, treatment, course, and prognosis information from the more developed literature bases, such as those for alcohol- and stimulant-related disorders. We believe in Redish’s approach noted earlier, meaning that the controversies inform a larger picture that can be home to multiple valid perspectives.

CURRENT STUDY The current study examined the potential clinical relevance of the sexual addiction diagnostic criteria in terms of endorsement rate in a treatment-seeking clinical sample, severity of sexual addiction in terms of DSM-V guidelines for severity of substance-related disorders, and in terms of criterion validity on the basis of the relationship with the Sexual Addiction Screening Test-Revised (SAST-R; Carnes et al., 2010) screener for sexual addiction. Criteria endorsement was examined by sex, sexual orientation, and setting. The study is structured to ask the general question whether the diagnostic



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criteria proposed by Carnes (2005) seem to have validity and utility in a clinical population of people seeking treatment for sexual addiction. Finally, given the controversy that exists about the nature of addiction, the nature of sex addiction, and even the utility of atheoretical diagnostic criteria, studying the data from a global perspective as well as a more refined specificity becomes even more useful. We have to examine whether the criteria cohere in a manner congruent with a syndrome, and whether any given criterion contributes unique information. Also, a very good case has been made by substance abuse researchers that not all the criteria may be necessary or desirable. They separate behavioral versus consequence variables, indicating the former are more useful as core criteria, and perhaps less stigmatizing (Martin et al., 2014)

METHODOLOGY

SAST-R is composed of a 20-item core scale, measuring the general construct of sexual addiction. In addition, the SAST-R contains 4 specific scales measuring vital characteristics of sexual addiction: preoccupation (4 items), loss of control (4 items), relationship disturbance (4 items), affective disturbance (5 items), and an internet scale (6 items) that comprises internet-related sexual activity. Finally, there are 3 scales (6 items) measuring behaviors intended to be more relevant to specific groups—heterosexual men, homosexual men, and women (both hetero- and homosexual). Formerly published psychometric data for the SAST-R concentrated on the core items (Carnes et al., 2010), reporting Cronbach α exceeding 0.75 for all groups, as well as adequate validity in terms of correct classification of sexually addicted and nonaddicted individuals.

Analytical Strategy

Participants Participants were 4492 patients, including 3951 men (88.0%) and 541 women (12%) presenting for inpatient (n = 345; 7.7%) or outpatient (n = 4147; 92.3%) treatment for sexual addiction. Regarding ethnicity, the sample consisted of 4016 (89.4%) individuals identifying as white, 135 (3.0%) identifying as black, 152 (3.4%) identifying as Hispanic, 56 (1.2%) identifying as Asian, and 133 (3.0%) identifying as “other.” In groups on the basis of sexual orientation, the sample consisted of 3561 heterosexual men, 164 homosexual men, 131 bisexual men, 429 heterosexual women, 18 homosexual women, and 61 bisexual women, with 129 not reporting sexual orientation. Data used were archival in nature, and data collection and use were approved by the University of Southern Mississippi institutional review board.

Instruments Diagnostic Criteria The diagnostic criteria discussed and reported on in this article are composed of 10 indicators of sexual addiction based on substance addiction criteria (Carnes, 2005). The 10 dichotomous items demonstrate excellent internal consistency for men (n = 3939; α = 0.872), women (n = 541; α = 0.906), and the combined sample (n = 4480; α = 0.878). The SAST-R (Carnes et al., 2010) is a 45-item screener for distinguishing possible cases of sexual addiction. The

The current study is exploratory in nature. First, we calculated endorsement rates, as well as Pearson χ 2 coefficients and ϕ effect sizes for sex differences in endorsement rate for each of the 10 criteria. Then, using substance use disorder severity rating criteria, we analyzed the frequency of different severity ratings among the current sexually addicted sample. Differences in total diagnostic criteria endorsement were examined by sex and setting (ie, inpatient vs outpatient), using Mann-Whitney analyses. In addition, Kruskal-Wallis analyses were utilized to examine potential within-sex differences in endorsement ratings by sexual orientation. With regard to the SAST-R, participants were first selected on the basis of the following clinical elevations of individual scales, recommended by Carnes et al. (2010): core (6+), preoccupation (2+), loss of control (2+), relationship disturbance (2+), affect disturbance (2+), internet (3+), men (2+), women (2+), and homosexual (3+). Frequencies of endorsement were calculated for each group for the 10 individual diagnostic criteria and reported descriptively. In addition, for each sex, SAST-R scale scores were compared on the basis of endorsement or nonendorsement of individual criteria via a series of t tests. To minimize type 1 error, α was set at P < 0.001.

RESULTS Table 3 presents the endorsement rates of the 10 criteria for the entire sample, broken down by sex, along with the Pearson χ 2 coefficients and ϕ effect sizes for sex

TABLE 3. χ 2 Analyses Comparing Men and Women on Individual Diagnostic Criteria Endorsement Criteria 1. Failed to resist impulses to engage in sex 2. Engaged more/longer than intended 3. Desire/unsuccessful efforts to stop 4. Excessive time to obtain/engage/recover 5. Obsessed with sexual activities 6. During major role obligations 7. Continued despite problems 8. Tolerance 9. Given up/limited activities 10. Withdrawal

454

Women Endorsing n (%)

Men Endorsing n (%)

Pearson χ 2

P

289 (53.4) 261 (48.2) 254 (47.0) 250 (46.2) 158 (29.2) 238 (44.0) 314 (58.0) 174 (32.2) 168 (31.1) 258 (47.7)

2948 (74.6) 2764 (70.0) 2758 (69.8) 2217 (56.1) 1289 (32.6) 2151 (54.4) 2738 (69.3) 1437 (36.4) 1513 (38.3) 2115 (53.5)

106.17 102.01 112.51 18.84 2.55 20.87 27.69 3.66 10.65 6.52

0.001 0.001 0.001 0.001 0.110 0.001 0.001 0.056 0.001 0.011

− 0.15 − 0.15 − 0.16 − 0.07 − 0.02 − 0.07 − 0.08 − 0.03 − 0.05 − 0.04

C




differences in endorsement rates. The percentage of endorsement for women ranges from 29.2% (criterion 5) to 58.0% (criterion 7). For men, endorsement rates range from 32.6% (criterion 5) to 74.6% (criterion 1). The χ 2 analyses are significant for all but 2 of the criteria (criteria 5 and 8), with greater proportions of men endorsing criteria compared with women. One sex difference emerging here is that the most highly endorsed criterion for men in treatment involves failure to resist sexual impulse, whereas for women it is continuing to engage in sexual behavior despite causing problems. The DSM-V (APA, 2014) delineates 3 severity levels for substance use disorders, including mild (2-3 criteria), moderate (4-5 criteria), and severe (6+ criteria). Using the same guidelines applied to sexual addiction, 13.3% of current sample were within the mild range, 15.4% were within the moderate range, and 53.1% were within the severe range. In addition, total diagnostic criteria endorsement was significantly higher in men (median = 6.00) than in women (median = 4.00) (U = 863,757; z = −7.28; P < 0.001). Within men, total diagnostic criteria endorsement was significantly higher in inpatient settings (median = 8.00) than in outpatient settings (median = 6.00) (U = 422,305.50; z = −7.25; P < 0.001). Within women, total diagnostic criteria endorsement did not differ between inpatient (median = 4.00) and outpatient settings (median = 4.00) (U = 9054.50; z = −0.29; P = 0.767). Furthermore, within men, total diagnostic criteria endorsement differed significantly by sexual orientation [H(2) = 42.17; P < 0.001]. Median endorsement was 6.00 for men identifying as heterosexual, 7.00 for men identifying as gay, and 7.00 for men identifying as bisexual or other. Within women, total diagnostic criteria endorsement also differed significantly by sexual orientation [H(2) = 11.51; P = 0.003]. Median endorsement was 4.00 for women identifying as heterosexual, 4.00 for women identifying as lesbian, and 6.00 for women identifying as bisexual or other. To test criterion validity, the individual scales of the SAST-R were used to select subjects for comparison on the basis of clinically significant elevations. The comparisons were conducted separately by sex. Endorsement frequencies were then calculated by the SAST-R scale for each diagnostic criterion (men, Table 4; women, Table 5). Mean endorsement rates for the SAST-R scales were above 60% for 7 of the 10 diagnostic criteria, regardless of the sex, suggesting that these criteria were salient to individuals presenting with the core elements of sexual addiction and related issues represented in the scales. Conversely, 3 of the 10 criteria (ie, obsession with preparing for sexual activity, demonstrating tolerance, and giving up activities because of sexual behaviors) had much lower endorsement rates (ie, between 41.27% and 49.29%) among both men and women. Therefore, these criteria may better serve as indicators of increased severity, rather than core criteria, for clinicians working in sexually addicted populations. Mean endorsement rates were generally similar (ie, within 5 percentage points) for men and women, across 7 of the 10 diagnostic criteria. However, women had substantially less endorsement than men on the following items: repeated failure to resist sexual impulses (12.15% difference), engagement in C


greater amounts or duration of sexual activity (11.96% difference), and failure to quit sexual activity despite desire and efforts to do so (14.74% difference). Although these items reflect problems that are highly prevalent among women, these differences in endorsement rates may suggest differences in clinical presentation and/or social norms between sexes. When examining each diagnostic criterion, there was some scatter in endorsement rates across the SAST-R scales. Among women, elevations on the affect disturbance scale were consistently associated with the lowest endorsement rates of all 10 criteria. Among men, elevations on the relationship disturbance scale were consistently associated with the lowest endorsement rates across all 10 criteria. In both sexes, elevations on the homosexual scale resulted in the highest endorsement rates of diagnostic criteria. To further assess construct validity, each individual criterion was examined, by sex, for differences on SAST-R scales between endorsers and nonendorsers Tables 6-15. Universally, individuals who endorsed each individual diagnostic criterion also scored significantly higher on all SAST-R scales than individuals who did not endorse the criterion. Also, endorsement of each criterion was associated with mean scores on all SAST-R scales above the clinical cutoffs for both sexes. Among women, nonendorsement of each of the diagnostic criteria was associated with clinically elevated mean scores on the core and affective scales of the SAST-R, albeit at a significantly lower level than endorsers. Furthermore, among men, nonendorsement of each diagnostic criterion was also associated with clinically elevated mean scores on the core, relationship disturbance, and affect disturbance scales. Furthermore, nonendorsement of criterion 4 (Table 9), criterion 5 (Table 10), criterion 6 (Table 11), criterion 8 (Table 13), criterion 9 (Table 14), and criterion 10 (Table 15), was associated with a clinically elevated mean score on the loss of control scale, among men. To sum up, those endorsing each of the 10 criteria scored significantly higher on the SAST-R core and component scales than nonendorsers. The finding that nonendorsers also had scale means above the cutoff for screening positive for some SAST-R scales should not be a surprise, as all participants were seeking treatment for sexual addiction. If they were not endorsing a given criterion, there is a good chance they were endorsing others.

DISCUSSION Given almost 50 years of controversy regarding diagnostic criteria among researchers of problematic sexual behavior, the literature is surprisingly congruent when distilled from an atheoretical perspective. Although disagreement remains as to the nomenclature (eg, sexual addiction and hypersexuality), researchers across several perspectives are relatively consistent with regard to descriptions of related phenomena. Controversy can generally be attributed to either a lack of empirical investigation for proposed criteria (eg, duration of symptoms) or a focus on etiology rather than phenomenology. As the literature was otherwise congruent, we assert that reasonably accurate measurement of the construct of sexual addiction should be possible apart from any consideration of etiological theories. The high prevalence rates of diagnostic criteria found among treatment-seeking individuals presenting with



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TABLE 4. Endorsement Rates of Diagnostic Criteria Among Men With Clinically Elevated SAST-R Scales

SAST-R Scales

Engaged Repeated More or Failure to Failure to Longer Quit Despite Resist Sexual Than Desire or Impulses Intended Attempts

Core (n = 3576), % Preoccupation (n = 2593), % Loss of control (n = 3238), % Relationship disturbance (n = 3627), % Affect disturbance (n = 3503), % Internet (n = 3069), % Men (n = 2931), % Women (n = 1560), % Homosexual (n = 676), % Mean, % SD, %

Excessive Obsessed Sexual Time With Behavior Obtaining/ Preparing for During Recovering Sexual Promised From Sex Activities Duties

Continued Sexual Behavior Despite Problems

Given Up or Limited Activities Because of Withdrawal Tolerance Sex Symptoms

81.24 87.43

76.15 83.69

76.37 83.19

61.21 72.58

35.65 44.97

59.12 69.34

75.34 82.26

39.65 49.21

41.61 50.02

57.10 68.34

86.26

80.57

82.95

65.23

38.39

62.82

79.62

42.74

44.47

59.79

78.03

73.50

73.17

59.42

34.30

57.51

72.90

38.35

40.23

55.45

81.16

76.11

76.62

61.43

35.91

59.21

75.34

39.99

41.94

57.04

82.54

78.10

78.07

63.93

37.37

61.94

76.70

42.13

43.73

58.42

83.18 84.62 91.72

79.32 82.76 89.94

78.74 80.06 87.72

66.87 75.51 86.83

39.71 48.46 56.66

64.48 69.68 77.22

78.37 82.82 90.38

43.84 51.15 59.02

45.45 53.27 61.98

60.73 67.05 72.93

84.02 4.05

80.02 4.96

79.65 4.39

68.11 8.81

41.27 7.39

64.59 6.39

79.30 5.29

45.12 6.75

46.97 7.01

61.87 6.08

SAST-R; Sexual Addiction Screening Test-Revised; SD, standard deviation.

TABLE 5. Endorsement Rates of Diagnostic Criteria among Women with Clinically Elevated SAST-R Scales

SAST-R Scales Core (n = 435), % Preoccupation (n = 279), % Loss of control (n = 334), % Relationship disturbance (n = 386), % Affect disturbance (n = 443), % Internet (n = 168), % Men (n = 118), % Women (n = 373), % Homosexual (n = 121), % Mean, % SD, %

Repeated Failure to Resist Sexual Impulses

Engaged More or Longer Than Intended

Failure to Excessive Obsessed Quit Time With Despite Obtaining/ Preparing Desire or Recovering for Sexual Attempts From Sex Activities

Sexual Behavior During Promised Duties

Continued Given Up or Sexual Limited Behavior Activities Despite Because of Withdrawal Problems Tolerance Sex Symptoms

64.83 75.99 79.94 66.58

58.62 72.76 71.56 62.18

57.24 70.25 71.56 60.36

56.55 69.89 66.17 58.03

36.32 51.25 44.01 38.08

52.87 65.95 61.98 55.70

70.57 81.00 80.54 72.54

39.31 52.69 49.40 41.71

38.16 50.90 46.41 41.45

56.55 71.68 64.67 58.03

63.21

57.11

55.08

54.18

34.54

51.02

68.17

37.92

36.79

53.72

77.98 77.97 64.34 76.03 71.87 6.92

76.79 77.12 58.71 77.69 68.06 8.78

72.02 72.03 57.91 67.77 64.91 7.14

73.21 73.73 59.25 85.12 66.24 10.19

53.57 53.39 38.61 62.81 45.84 9.80

68.45 67.80 55.23 78.51 61.95 9.03

80.95 80.51 70.51 88.43 77.02 6.79

57.14 62.71 40.75 61.98 49.29 9.83

59.52 53.39 40.21 62.81 47.74 9.47

73.21 75.42 58.71 82.64 66.07 10.05

SAST-R; Sexual Addiction Screening Test-Revised; SD, standard deviation.

TABLE 6. Relationship Between Endorsement of Criterion 1 and SAST-R Scales* Women

Core Preoccupation Loss of control Relationship disturbance Affective disturbance

Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

6+ 2+ 2+ 2+ 2+

13.75 (3.48) 2.25 (1.16) 3.19 (1.11) 2.70 (1.07) 4.14 (1.05)

6.63 (4.05) 0.87 (0.91) 0.89 (1.13) 1.40 (1.16) 2.45 (1.71)

− 21.76† − 15.46† − 23.80 13.54† − 13.82†

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

0.001 0.001 0.001 0.001 0.001

13.88 (3.17) 2.19 (1.06) 3.43 (0.91) 3.45 (0.84) 3.95 (1.06)

7.56 (4.07) 1.06 (0.97) 1.47 (1.28) 2.41 (1.20) 2.29 (1.48)

− 44.74† − 31.27 − 52.77† − 25.37† − 32.68†

0.001 0.001 0.001 0.001 0.001

*Repeatedly failed to resist sexual impulses to engage in a specific sexual behavior. †Equal variances not assumed. SD, standard deviation.

456

C







Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

6+ 2+ 2+ 2+ 2+

14.03 (3.49) 2.34 (1.14) 3.17 (1.13) 2.84 (1.02) 4.19 (1.05)

7.09 (4.13) 0.92 (0.91) 1.14 (1.33) 1.41 (1.12) 2.60 (1.71)

−21.17† −15.88† −19.28† −15.48† −13.13†

0.001 0.001 0.001 0.001 0.001

14.02 (3.13) 2.23 (1.05) 3.44 (0.92) 3.49 (0.80) 3.99 (1.03)

8.22 (4.23) 1.13 (0.98) 1.75 (1.38) 2.48 (1.19) 2.46 (1.50)

−42.42† −30.88 −38.69† −26.83† −31.90†

0.001 0.001 0.001 0.001 0.001

Denied Mean (SD)

t

P

−45.26† −29.03 −47.55† −23.97† −34.34†

0.001 0.001 0.001 0.001 0.001

*Frequently engaged in sexual behaviors to a greater extent or over a longer period than intended. †Equal variances not assumed. SD, standard deviation.



Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

6+ 2+ 2+ 2+ 2+

14.15 (3.35) 2.30 (1.14) 3.30 (1.02) 2.81 (1.00) 4.23 (1.07)

7.15 (4.17) 1.00 (1.01) 1.08 (1.26) 1.47 (1.19) 2.60 (1.70)

−21.63† −13.98† −22.58† −14.24† −13.66†

0.001 0.001 0.001 0.001 0.001

14.10 (3.00) 2.22 (1.04) 3.52 (0.81) 3.47 (0.82) 4.02 (1.00)

8.05 (4.18) 1.17 (1.04) 1.58 (1.31) 2.54 (1.22) 2.41 (1.48)

Denied Mean (SD)

t

P

9.24 (4.13) 1.24 (0.95) 2.15 (1.42) 2.66 (1.16) 2.80 (1.46)

− 46.55† − 38.11† − 36.17† − 29.37† − 31.55†

0.001 0.001 0.001 0.001 0.001

*Long-standing desire, or a history of unsuccessful efforts to stop, reduce, or control sexual behaviors. †Equal variances not assumed. SD, standard deviation.



Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

6+ 2+ 2+ 2+ 2+

13.94 (3.64) 2.34 (1.17) 3.10 (1.22) 2.83 (1.04) 4.20 (1.09)

7.43 (4.32) 0.97 (0.93) 1.28 (1.40) 1.47 (1.15) 2.65 (1.69)

− 19.04† − 14.91† − 16.14† − 14.47† − 12.82†

0.001 0.001 0.001 0.001 0.001

14.65 (2.86) 2.42 (1.01) 3.54 (0.85) 3.60 (0.72) 4.10 (1.00)

*Spent excessive time in obtaining sex, being sexual, or recovering from sexual experiences. †Equal variances not assumed. SD, standard deviation.



Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

6+ 2+ 2+ 2+ 2+

15.01 (3.35) 2.75 (1.06) 3.39 (1.05) 3.01 (0.97) 4.29 (0.99)

8.55 (4.58) 1.13 (0.99) 1.60 (1.49) 1.72 (1.22) 2.98 (1.70)

− 18.20† − 16.44† − 15.83† − 12.94† − 11.17†

0.001 0.001 0.001 0.001 0.001

15.30 (2.64) 2.66 (0.98) 3.67 (0.73) 3.60 (0.74) 4.26 (0.92)

10.81 (4.32) 1.54 (1.03) 2.57 (1.40) 2.99 (1.11) 3.18 (1.43)

− 40.25† − 32.38 − 32.16† − 20.29† − 28.60†

0.001 0.001 0.001 0.001 0.001

*Obsessed with preparing for sexual activities. †Equal variances not assumed. SD, standard deviation.

elevations on the SAST-R suggest that the proposed criteria are highly applicable to individuals presenting for treatment for sexual addiction. In addition, the generally high rates of endorsement of these criteria among participants elevated on the SAST-R scales support both the construct and criterion validity of these criteria. Variations in endorsement rates may C

inform clinicians of the relative severity of an individual presenting for treatment. For example, endorsement of one of the 3 criteria, which had consistently lower prevalence rates (ie, obsession with preparing for sex, tolerance, and giving up activities because of sex), may indicate that an individual is experiencing greater severity of symptoms.



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Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

6+ 2+ 2+ 2+ 2+

13.67 (3.74) 2.29 (1.18) 3.04 (1.28) 2.85 (1.01) 4.08 (1.16)

7.90 (4.70) 1.40 (1.45) 1.40 (1.45) 1.51 (1.17) 2.80 (1.73)

− 15.91† − 12.75† − 13.96† − 14.29† − 10.31†

0.001 0.001 0.001 0.001 0.001

14.44 (3.10) 2.38 (1.03) 3.50 (0.90) 3.61 (0.73) 4.03 (1.05)

9.69 (4.31) 1.33 (1.01) 2.25 (1.43) 2.69 (1.14) 2.93 (1.49)

− 39.08† − 32.39 − 31.96† − 29.35† − 26.21†

0.001 0.001 0.001 0.001 0.001

*Frequently engaged in sexual behavior when expected to be fulfilling occupational, academic, domestic, or social obligations. †Equal variances not assumed. SD, standard deviation.

TABLE 12. Relationship Between Endorsement of Criterion 7 and SAST-R Scales Women


Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

6+ 2+ 2+ 2+ 2+

13.38 (3.65) 2.15 (1.19) 2.94 (1.29) 2.68 (1.05) 4.14 (1.07)

6.37 (4.08) 0.85 (0.90) 0.98 (1.26) 1.29 (1.15) 2.29 (1.68)

− 20.61† − 14.42† − 17.60 − 14.44† − 14.59†

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

0.001 0.001 0.001 0.001 0.001

14.02 (3.16) 2.24 (1.05) 3.43 (0.94) 3.49 (0.81) 3.98 (1.05)

8.33 (4.22) 1.14 (0.97) 1.81 (1.39) 2.51 (1.20) 2.52 (1.50)

− 42.09† − 30.91 − 36.92† − 25.95† − 30.49†

0.001 0.001 0.001 0.001 0.001

*Continued sexual behavior despite knowing it has caused or exacerbated social, financial, psychological, or physical problems. †Equal variances not assumed. SD, standard deviation.



Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

6+ 2+ 2+ 2+ 2+

14.81 (3.19) 2.59 (1.14) 3.38 (0.98) 2.93 (0.99) 4.33 (0.99)

8.37 (4.61) 1.14 (1.01) 1.52 (1.49) 1.70 (1.23) 2.91 (1.68)

− 18.89† − 14.28† − 17.33† − 12.37† − 12.30†

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

0.001 0.001 0.001 0.001 0.001

15.12 (2.73) 2.58 (1.00) 3.64 (0.77) 3.60 (0.74) 4.23 (0.92)

10.65 (4.33) 1.52 (1.04) 2.53 (1.41) 2.96 (1.12) 3.13 (1.44)

− 39.77† − 31.25 − 31.90† − 21.50† − 29.40†

0.001 0.001 0.001 0.001 0.001

*Tolerance: need to increase the intensity, frequency, number, or risk of sexual behaviors to achieve the desired effect, or experience diminished effect when continuing behaviors at the same level of intensity, frequency, number, or risk. †Equal variances not assumed. SD, standard deviation.



Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

6+ 2+ 2+ 2+ 2+

14.81 (3.40) 2.63 (1.15) 3.32 (1.13) 3.08 (0.90) 4.29 (1.01)

8.45 (4.59) 1.15 (1.00) 1.58 (1.48) 1.65 (1.19) 2.95 (1.69)

− 17.91† − 14.42† − 14.92† − 15.44† − 11.39†

0.001 0.001 0.001 0.001 0.001

14.88 (2.92) 2.49 (1.03) 3.59 (0.84) 3.59 (0.77) 4.17 (1.00)

10.66 (4.38) 1.54 (1.05) 2.53 (1.41) 2.94 (1.12) 3.13 (1.44)

− 36.31† − 27.97 − 29.27† − 21.62† − 26.90†

0.001 0.001 0.001 0.001 0.001

*Given up or limited social, occupational, or recreational activities because of sexual behavior. †Equal variances not assumed. SD, standard deviation.

With this established, we can begin to examine the criteria themselves, as well as their relative construct validity. We examined the criteria within a known clinical sample to establish the self-reported prevalence for each of these items, as well as to ascertain possible sex differences. Our findings

458

support the use of the 10 diagnostic criteria, initially proposed by Carnes (2005). Findings of this exploratory study suggest that screening and diagnosis of sexual addiction will be similar across sexes in regard to most of the criteria, but not all. Although diagnostic criteria are frequently summed and C







Men

Cutoff

Endorsed Mean (SD)

Denied Mean (SD)

t

P

Endorsed Mean (SD)

Denied Mean (SD)

t

P

6+ 2+ 2+ 2+ 2+

13.50 (4.17) 2.33 (1.20) 2.97 (1.35) 2.71 (1.12) 4.00 (1.28)

7.65 (4.35) 0.95 (0.88) 1.34 (1.40) 1.54 (1.17) 2.78 (1.71)

− 15.94 − 15.18† − 13.70 − 11.86† − 9.41†

0.001 0.001 0.001 0.001 0.001

14.14 (3.49) 2.41 (1.04) 3.43 (1.02) 3/45 (0.87) 3.95 (1.15)

10.13 (4.34) 1.32 (0.98) 2.36 (1.41) 2.88 (1.14) 3.05 (1.46)

− 31.71† − 34.06† − 26.89† − 17.53† − 21.31†

0.001 0.001 0.001 0.001 0.001

*Withdrawal symptoms: become upset, anxious, restless, or irritable if unable to engage in sexual behavior. †Equal variances not assumed. SD, standard deviation.

examined as a composite score in clinical practice (to identify the presence or absence of sexual addiction), findings suggest that certain criteria hold more salience (as evinced by higher endorsement) to specific individuals presenting for treatment of sexual addiction. In addition, a few criteria may pose a higher clinical threshold and thus be utilized by clinicians to identify patients with increased pathology. These criteria include engaging in sexual behaviors during times allotted for role obligations, needing to increase the intensity/frequency/amount of sexual behaviors to achieve the same effect (tolerance), and giving up or limiting activities because of sexual behaviors. It is possible that one high-severity item is missing from our proposed criteria. Specifically, a criterion measuring continued sexual behavior despite experiencing severe health consequences should be investigated for possible diagnostic inclusion. For illustrative purposes, the example of an individual dependent upon alcohol and experiencing liver failure is offered. Given the severity of liver failure, it may be reasonably concluded that this individual is experiencing not only physical consequences, but that they would also endorse a wide range of other criteria. The current criterion of “continuation of the sexual behavior despite knowledge of having persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior” (Carnes, 2005, p. 1997) encompasses this proposed criterion. However, the inclusion of a broad range of problems dilutes the severity of the item, as an individual who separates from their significant other is assumed to experience the same distress or difficulty as an individual who contracts AIDS. There is an obvious difference between the 2 individuals, and clinicians may benefit from the ability to diagnostically differentiate them. Furthermore, apparent functional disturbance, within physical, psychological, social, or occupational domains, should be considered as a required criterion within the diagnostic framework. Conversely, subjective distress may be included as a possible, though nonessential, criterion. The logic of this requirement is illustrated in the previous example. If an alcoholic reports no distress but is intoxicated daily, unable to work, and experiencing liver damage, the individual likely warrants diagnosis. In addition, we suggest that criteria related to duration of symptoms required for diagnosis be forestalled, pending empirical investigation. Finally, several diagnostic frameworks agree on exclusionary criteria (Stein et al., 2001; Coleman et al., 2003; Kafka, 2010), each with unique and useful contri C

butions. With these recommendations in mind, the following exclusionary criteria are offered: symptoms are not better accounted for by a medical condition, symptoms are not limited to the effects of an exogenous substance (eg, medication or substance of abuse), a manic episode, erotomanic delusions, or other psychological condition or disorder (eg, obsessive compulsive disorder and developmental disorder). Finally, findings regarding these diagnostic criteria lend support to an addiction model of hypersexuality. Patients seeking treatment for sexual addiction endorse items related to dependence, tolerance, and withdrawal at relatively high rates, similar to individuals with alcohol, drug, and gambling addictions (Basu et al., 2000). Overall, the findings of this study support the use of the diagnostic criteria along with the SASTR as part of sexual addiction diagnosis and case formulation, as each component adds valuable and unique clinical information.

Limitations This exploratory study has several limitations. First and foremost, group overlap on basic diagnostic criteria and screening scales may mask differences between the various cognitive and behavioral manifestations of sexual addiction. For example, people who are focused on sexually predatory behavior toward adults and people who are focused on sexually predatory behavior toward children, or otherwise vulnerable individuals, may both engage in excessive use of the internet for sexual purposes, but differ in the ways they use the internet. In such a case, diagnostic criteria that relate solely to excessive internet use are unlikely to help differentiate between those 2 groups. Likewise, the 10 criteria and the SAST-R are unlikely to differentiate people with such preferences. Further research examining how the diagnostic criteria relate to specific behavioral and preoccupational pathways, through which sexual addiction may be expressed, could identify constellations of criteria that are more relevant to one form of expression versus another. Other limitations derive from the sample characteristics. We do not yet have numbers that will allow us to examine potential differences among sexual orientations and across sexes simultaneously. Lastly, as yet we have no data for the diagnostic criteria among nonclinical samples. We need to at least establish tentative nonclinical norms as references for the clinical response ranges for the instruments used here.



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Our goal in this study was to demonstrate how the proposed diagnostic criteria for sex addiction parallel those from various authors and models in the field, and then to examine how those criteria relate to other indicators of excessive sexual behavior in a clinical population, to validate and extend our understanding of the construct. Thus, our purpose is to open the door to future research.

Future Directions Moving forward, the study of diagnostic criteria of sexual addiction would benefit from a comparison of endorsement among clinical and nonclinical groups. In addition, determination of the sensitivity and specificity of individual criteria, as with receiver operating characteristic analysis and/or item response analysis, may be beneficial. It may also be beneficial to ascertain whether a given criterion is more or less predictive of a given sexual behavior, and whether these predictions differ between sexes and sexual orientations. Such information would add clinical utility to the criteria by informing clinicians about likely manifestations associated with a given item. There is also value in examining the interdependence of items, to ensure that each individual item contributes to the variance accounted for by the overall diagnostic framework, thereby determining that none of the items is redundant or superfluous. Furthermore, it would be advantageous to examine how these diagnostic criteria perform among higher order factors comprising groups of particular behaviors, to obtain the most parsimonious understanding of sexual addiction. Finally, future studies should expand upon clinical understanding and incorporate personality measures, such as the Minnesota Multiphasic Personality Inventory-2 (Butcher et al., 2001), to ascertain whether the scoring patterns and differences found thus far are sustained in other areas of psychological functioning. By this time, readers may have asked themselves what happened to the criteria for sex addiction in the DSM-III-R. There was a strong reaction in the Women’s Movement of the day that sex addiction was another method for excusing bad behavior in men. We do not know whether the controversies affected the decision, but the criteria were removed from the DSM-IV. You cannot talk about sex without politics and controversy. Our culture has a long history of using sexual judgment to influence culture and politics. Science, however, is a collective set of conversations about how we know what we know. That is our purpose. As Don Hilton (2013) reminded us in his critique of some of sex addiction’s critics, it was the insight of Kuhn about the evolution of science, emerging paradigms engendered great controversy. Furthermore, we would add: integrating paradigms often validate what at first seemed contradictory. REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., rev. Washington, DC: APA, 1987. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA, 1994. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, DC: APA, 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: APA, 2013.

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Sexual addiction: designation and treatment.

Examining the diagnostic criteria for Internet addiction: Expert validation.

How Preclinical Models Evolved to Resemble the Diagnostic Criteria of Drug Addiction.

Sexual addiction: insights from psychoanalysis and functional neuroimaging.

Cybersex addiction: Experienced sexual arousal when watching pornography and not real-life sexual contacts makes the difference.

Core and peripheral criteria of video game addiction in the game addiction scale for adolescents.

Assessment of a proposed "three-criteria" cocaine addiction model for use in reinstatement studies with rats.

Less than meets the eye: reappraising the clinical relevance of attentional bias in addiction.

Fronto-striatal circuits in response-inhibition: Relevance to addiction.

Alcohol, stress hormones, and the prefrontal cortex: a proposed pathway to the dark side of addiction.

Characteristics of self-identified sexual addicts in a behavioral addiction outpatient clinic.

Examining the Application of the DC-IA-A Diagnostic Criteria for Internet Addiction Disorder in At-Risk College Students.

Effectively addressing addiction requires changing the language of addiction.

Triangular relationship among risky sexual behavior, addiction, and aggression: A systematic review.

Marital satisfaction during recovery from self-identified sexual addiction among bisexual men and their wives.

The human hypothalamus in relation to gender and sexual orientation.

Evolutionary and neuropsychological perspectives on addictive behaviors and addictive substances: relevance to the "food addiction" construct.

Addiction to diazepam.

Development and content validity of a screening instrument for gaming addiction in adolescents: the Gaming Addiction Identification Test (GAIT).

Addiction.

The neurobiology of tobacco addiction.

Stress Mediates the Relationship Between Past Drug Addiction and Current Risky Sexual Behaviour Among Low-income Women.

Breaking the addiction to technology adoption.

Addiction: Road to aversion.